Electroconvulsive Therapy Is Not What You Think It Is

If you think modifying the brain with electricity sounds like shock therapy, well, that’s understandable. That imagery has been embedded in the American psyche thanks to inaccurate depictions on TV and in movies, not to mention outdated (and unethical) “treatments” from the past. 

However, modern electroconvulsive therapy (ECT) and other similar therapies are nothing like those old practices. Instead, they are part of a brighter future for minimally-invasive psychiatric treatments known as neuromodulation therapy. They make a huge difference in the lives of patients whose brains are not responding or are resistant to traditional approaches like medications or talk therapy. 

How does neuromodulation work? 

Neuromodulation involves adjusting or rebalancing the nervous system and is usually focused on the brain. This includes everything from cochlear implants for deafness to deep brain stimulation to treat epilepsy and Parkinson’s disease among other neurological disorders.  

“These therapies can be applied throughout the body and brain to modulate or change abnormal connections to restore normal communication and function between neurons,” says Dr. Randall Espinoza, a geriatric neuropsychiatrist who leads the Garvey Institute Center for Neuromodulation at the UW Medicine Center for Behavioral Health and Learning.

ECT and transcranial magnetic stimulation (TMS) are recognized for their safety and effectiveness. They’ve been around for a while, providing hope for people with severe mental health disorders.  

Exactly how ECT and TMS work is unknown, but recent research suggests both treatments alter the levels of certain neurotransmitters, neurotrophic factors and hormones in the brain and stimulate the brain to make new connections. 

Here’s what you need to know about both treatments. 

ECT is like restarting your brain 

ECT is approved for use among people who have severe depression, bipolar depression and catatonia, regardless of cause. With appropriate clinical evaluation, ECT can also be used for other disorders like schizophrenia. Despite its name, ECT doesn’t involve full-body convulsions like those seen in some forms of epilepsy. During treatment (and while the person is under general anesthesia) electrodes are placed in specific locations on the scalp, and a mild electrical current is turned on. This current creates a controlled, short seizure typically lasting between 30 to 60 seconds.  

“One thing that’s a surprise to people is the amount of electricity that is applied is quite small; we support the jaw and face during ECT without feeling electrical stimulation ourselves,” says Dr. Brandon Thomas, a psychiatrist who specializes in neuromodulation at the Center for Behavioral Health and Learning. “If the machine goes to the highest setting, it would light a standard light bulb for less than a second.” 

Thomas compares it to restarting a computer when it’s freezing or acting up — it helps the machine work better and doesn’t break anything. The brain isn’t a machine, of course, but it does have its own electrical connections. 

“ECT can change people's lives fundamentally; few other treatments can have that huge of an effect so quickly,” says Thomas. 

While the electricity is delivered to the brain, doctors monitor the patient’s brain activity via an electroencephalogram (EEG) and other body functions like heart rate and rhythm, blood pressure and oxygenation levels. Multiple regulatory and scientific bodies have found it is safe and effective when used with modern techniques. The Food and Drug Administration (FDA) regulates ECT devices, and ECT has been endorsed by the American Psychiatric Association and other professional and scientific groups from around the world.  

How long does someone have to do ECT? 

Typically, in the beginning, someone will go to the clinic or hospital a few times a week for treatment; this lasts from a couple of weeks to a month, for a total of six to 12 treatments for most patients. The goal is to achieve as much improvement as possible during this phase. Someone else needs to drive the patient to and from treatment. 

Afterwards, a patient may need additional sessions of ECT or may take medications to prevent their mental illness symptoms from returning after the initial ECT treatments are completed. 

Are there side effects to ECT?  

The most notable potential side effect of ECT is memory loss. Typically, this involves short-term memory loss in which someone may not remember things that happened right before treatment began. (The anesthesia, of course, can contribute to this problem, as can untreated depression or other medications.) Any short-term memory loss during the first course of treatment usually resolves by a few weeks after the treatment has been completed, says Thomas. 

“Often with depression, your concentration and focus are negatively impacted,” Thomas says. “Many people find that after ECT, their cognition improves as their depression is treated.” 

Sometimes, a person might experience longer-term memory loss after ECT, usually of memories formed in the months right before or during treatment. And it may take time for some specific distant or remote memories to return, or these may never return. Importantly, you won’t forget who you are, how to tie your shoes, who your loved ones are or anything else foundational to your existence.  

Memory loss of past events is the most worrisome ECT risk. However, for people who are struggling just to survive, the risk of losing a few memories is often worth being able to function again, to resume important roles like being a parent or to return to school or work. 

TMS is like a painless little brain boost 

TMS can be used to treat major or chronic depression, obsessive-compulsive disorder (OCD) and anxious depression, which is when a depressed patient has anxiety at the same time. It can also help someone quit smoking.  

TMS uses a magnetic field to stimulate neurons. Like ECT, it’s noninvasive, meaning no incisions or implants are needed. TMS was approved by the FDA in 2008, so while you might not have heard of it, its effectiveness has been known for a while. 

Research has shown that parts of the brain involved in mood regulation are less active when someone is depressed, so stimulating those parts during TMS is thought to activate them, which then helps relieve depression symptoms. 

One cool thing about TMS? Someone can sit up and read or listen to music while receiving the treatment. That’s because TMS doesn’t cause a brain seizure, so no anesthesia is required. Patients sit while the device is placed on their head — it looks kind of like one of those old-timey salon hair dryers. Someone can drive themselves to and from their appointment.  

How long does someone have to do TMS?  

The first treatment session lasts longest, at about an hour. Subsequent TMS sessions are brief, usually lasting about 20 minutes, five days a week, for four to six weeks. 

Are there side effects to TMS? 

TMS has very few side effects, and even those tend to be mild. After a TMS session, someone might feel lightheaded, have a headache or have twitchy face muscles. These symptoms usually go away quickly and happen less as treatment progresses. 

Who can get ECT and TMS? 

No one can give you ECT, TMS or any other type of neuromodulation against your will. In rare cases, someone may be given neuromodulation therapy when they are too ill to consent or are mandated by a court, but that is only done in situations where their life may be at risk and in an effort to help get them better as quickly as possible. 

You also can’t receive neuromodulation treatments just by asking for them; there are many different factors that make someone eligible (or not). 

“Neuromodulation therapies are done after careful assessment to ensure an appropriate diagnosis and indication, after obtaining informed consent where at all possible, and after a thorough medical evaluation and review where needed,” Espinoza explains.  

Sometimes, psychiatrists use neuromodulation along with other therapies, such as medication or talk therapy. Neuromodulation therapies like ECT and TMS are covered by many health insurance plans. 

If other treatments aren’t working for you, it’s worth discussing with your doctor or psychiatrist if you’re a good candidate for neuromodulation. 

The brain dump 

If you live in Washington state, you have access to ECT and TMS treatments at the Garvey Institute Center for Neuromodulation in UW Medicine’s new Center for Behavioral Health and Learning. Espinoza hopes to bring on and develop other types of neuromodulation at the Center, such as vagus nerve stimulation, magnetic seizure therapy and deep brain stimulation — with the goal of creating a new era of more effective mental health treatment.

“Although it’s improving, there is still considerable shame and stigma associated with having a brain health condition or with seeking treatment,” Espinoza says. “It’s important for people to know that these disorders can be treated and that people can get better.” 

If you’re struggling with your mental health, don’t be afraid to reach out — to a friend, a doctor, a therapist or someone else you trust. A better future is possible, whether that involves neuromodulation therapies or something else.